Template

BAIE Near Miss Notification Form

by Sarah Hollister, from the Community

This Near Miss Notification Form helps teams capture and report events that could have resulted in injury, illness, or damage but did not. Based on OSHA’s near-miss definition, the template guides users to record date and time, exact location, detailed descriptions, and contributing factors. It includes selectable categories such as falls from height, trips or same-level falls, electric shock, hazardous substances, falling objects, and more, enabling faster analysis and corrective action. Use this checklist to standardize reporting, strengthen hazard awareness, and improve safety performance across construction sites and similar work environments.

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Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

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Confirm accountability and compliance with a digital log

With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
Near Miss Report Form Template
Use this Near Miss Report Form template to capture unplanned events that could have led to injury, illness, environmental harm, or disruption. Based on the IOSH definition, it guides users to record date and time, location, incident category (falls, manual handling, electric shock, hazardous substances, and more), detailed incident description, root causes, lessons learned, and corrective actions. Add supporting photos, capture optional employee details and signatures, and include approvals for closure. Designed for construction and general workplace safety teams to strengthen hazard reporting, analyze trends, and prevent future incidents.
by Chris Skelton, from the Community
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Template
K Near Miss Form for Construction Sites
Use this near miss form to standardize reporting on construction sites. Capture company and contractor details, date and time, weather, location, and the category of the near miss such as falls, trips, electric shock, caught between, falling objects, or equipment. Document the description, hazards, affected employees, property damage, and any machinery involved. Identify root causes across equipment, procedures, training, environment, and tools. Assess severity and possible outcomes, record worker statements, and add photos. Define corrective actions, note follow up, and capture lessons learned with name and signature fields.
by Rick Delmonico, from the Community
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Template
DRS Near Miss Notification Form
Use this near miss notification form to quickly capture and report workplace safety near miss events. Record date and time, location or customer site, company cell and vehicle number, a clear description of what happened, contributing factors, and what was learned or changed. Attach photos for clarity and sign to confirm accuracy, then email the completed form to the Health and Safety Manager or Claims Manager for follow up.
by Chris Reynolds, from the Community
Downloads: 2,000+
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Template
Checklist para Operadores de Infraestructura
Use this Near Miss Report Form template to capture unplanned events that could have led to injury, illness, environmental harm, or disruption. Based on the IOSH definition, it guides users to record date and time, location, incident category (falls, manual handling, electric shock, hazardous substances, and more), detailed incident description, root causes, lessons learned, and corrective actions. Add supporting photos, capture optional employee details and signatures, and include approvals for closure. Designed for construction and general workplace safety teams to strengthen hazard reporting, analyze trends, and prevent future incidents.
by Chris Skelton, from the Community
Downloads: 0
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BAIE Near Miss Notification Form

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Near Miss Report Form Template

K Near Miss Form for Construction Sites

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Checklist para Operadores de Infraestructura

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Near Miss Report Form Template

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